Peds Endorse Telemedicine With Caveats

But not all virtual healthcare is good for patients, committee cautions

Action Points

Note that this statement from the American Academy of Pediatrics encourages the use of telemedicine as part of the patient-centered medical home.

Be aware that reimbursement policies for telemedicine vary considerably by insurance providers.

Use of telemedicine for patient care is appropriate when integrated into the patient-centered medical home (PCMH) model, according to the first ever policy statement on telemedicine by the American Academy of Pediatrics.

James P. Marcin, MD, MPH and colleagues from the AAP Committee on Pediatric Workforce called for use of telemedicine services within the PCMH as a way to expand the quality and efficiencies of patient care and streamline its cost.

However, the committee discouraged "fragmented care" from third party providers, such as retail health clinics, because it disrupts care and undermines the PCMH model, they wrote in Pediatrics.

Efficiency was another advantage for clinicians using telemedicine. So-called "eReferrals" -- where a primary care provider discusses a patient's condition with a specialist via telemedicine prior to an in-person referral, have been shown to increase primary care provider knowledge and actually decrease the amount of in-person referrals. The authors wrote that telemedicine programs have also led to more appropriate specialist referrals, as well as fewer diagnostic redundancies -- especially for children with special health needs.

Mary Ellen Rimsza, MD, chairperson of the AAP Committee on Pediatric Workforce, gave examples of how telemedicine is helping patients in her home state of Arizona, where telemedicine is being used to provide psychiatric care to children and adolescents in rural areas.

"Telemedicine can improve access to pediatric care, especially in pediatric medical and surgical specialties where there are significant shortages of these specialists," she told MedPage Today. "Using telemedicine can help us make better use of specialists who are in short supply and thus provide care to more patients."

In addition, she added how telemedicine is being used to coordinate care for children with serious medical conditions, such as newborns with suspected congenital heart disease.

"The cardiologist who is based at the University of Arizona in Tucson has trained ultrasound technicians in rural communities such as Yuma to do echocardiograms, transmit the echo to them, review the echo and then communicate the results to the pediatrician who is providing care," she said.

With these consultations occurring remotely, telemedicine also can contribute to reduced cost of care. Cost analyses have shown long-term cost savings from telemedicine, including reductions in the duplication of medical tests, use of tertiary care centers, as well as increased communication efficiencies. The authors also describe more public health benefits, such as reduced transportation costs and less hours of missed work or school by the patient and his/her guardian due to traveling for medical appointments.

But cost -- specifically payment -- is a barrier to telemedicine. The committee writes that it is difficult for providers to receive reimbursement for telemedicine consultations, particularly from public insurance. The Centers for Medicare and Medicaid Services has restrictive policies regarding the use of telemedicine. They note that changes in care delivery from the ACA and "value-based" care may help secure financial incentives for telemedicine, which is crucial to its future growth.

The growth of telemedicine as a third party industry from retail clinics and "virtual healthcare services" was especially troubling to the committee. Marcin told MedPage Today that because these companies operate outside of the "medical home" concept and the patient's regular pediatrician, the care that patients receive is fragmented. He also pointed out that pediatricians often provide continuous access, with telephone lines and triage help, but are not reimbursed for their services by insurance.

"These companies are coming in and doing it and getting paid by the insurance company, but the pediatricians don't get paid for that, so it was part of the thought behind creating this policy, saying that we have to do this the right way," Marcin said.

He added that these companies further shift the disparities of care because of the cost involved in their use. "Not everybody can afford to swipe a credit card to get immediate online help from a physician or a nurse, so it's providing a disruptive service to the medical home."

The committee concluded that further regulatory and licensing for telemedicine by states and local governments is needed, as well as research that demonstrates its effectiveness in reducing healthcare costs. They also recommended financial incentives such as tax credits, loan forgiveness programs, and technology grants to physicians, practices, and health systems that can prove telemedicine increases efficiency, reduces cost, and improves performance.

"The use of the technologies is increasing and it's incumbent upon the pediatric providers to make sure that it is used in the best way for child health," Marcin said. "There are lots of opportunities to use these technologies to do the right thing, so we want to make sure pediatricians are aware of what's going on, on board with it and get involved to ensure its appropriate application."

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